MEDICARE: SULPHUR SPRINGS CHILDREN'S DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center
2	122300000X	Dentist

General Provider Information

NPI Number	:	1043923337
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SULPHUR SPRINGS CHILDREN'S DENTISTRY

Provider Business Mailing Address
First Line	:	226 MAIN ST
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75482-2707
Country	:	US
Telephone Number	:	903-558-1260
Fax Number	:	903-558-1262

Provider Business Practice Location Address
First Line	:	226 MAIN ST
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75482-2707
Country	:	US
Telephone Number	:	903-558-1260
Fax Number	:	903-558-1262

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	DR. BENNETT JOE VACULIK
Credential	:	DDS
Telephone Number	:	903-243-4790

Provider Enumeration Date	:	01/02/2023
Last Update Date	:	03/14/2023

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